Recommendations

for psychiatrists
on spirituality and religion
Position Statement PS03/2011
August 2011
Royal College of Psychiatrists
London
Approved by Central Policy Coordination Committee: May 2011
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Authorship
This position statement was written by Professor Christopher C. H. Cook,
MD, PhD, FRCPsych, on behalf of the Spirituality and Psychiatry Special
Interest Group. The Executive Committee of the Spirituality and Psychiatry
Special Interest Group wishes to record its appreciation of the advice given
on the production of this Position Statement by the Policy Committee and
Professional Practice & Ethics Sub-Committee of the College.
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Introduction
The aims of this position statement are to affrm the value of considering
spirituality and religion as a part of good clinical practice and to provide
guidance which will clarify and affrm the boundaries of good practice. It
draws upon the current evidence base, published debate, and the aspirations
of service users as expressed in published surveys and informal contacts.
The Royal College of Psychiatrists believes that such guidance is important
for the protection of both patients and psychiatrists. Further, such guidance
is necessary in order to ensure that matters of spirituality and religion are
not avoided in clinical practice when in fact they may need to be addressed
for the beneft of the patient, but at the same time to ensure that a patients
lack of religious or spiritual beliefs is equally respected.
BACKGROUND
In 1990 the American Psychiatric Association (APA) published Guidelines
Regarding Possible Confict Between Psychiatrists Religious Commitments
and Psychiatric Practice, which emphasised the need for psychiatrists to
respect their patients beliefs and warned against imposition of psychiatrists
beliefs on their patients.
1
These guidelines provide ethical and professional
boundaries within which matters of religion and belief may properly be
attended to by psychiatrists, for the beneft of their patients, while ensuring
that potential conficts between beliefs of psychiatrist and patient are
handled appropriately and that potential abuses are avoided.
The Section on Religion, Spirituality and Psychiatry (SRSP) of the
World Psychiatric Association has also pursued a process intended to lead to
international agreement on a consensus or position statement on spirituality
and religion in psychiatry. This process has not yet resulted in a consensus
owing primarily to particular cultural and historical concerns specifc to
certain member organisations.
2
However, the aspirations in pursuing this
process have been similar to those of the APA; the need both to affrm
appropriate exploration of the ways in which spirituality and religion should
be addressed in psychiatric practice and research, and to ensure that proper
boundaries are maintained and abuses prevented.
Recent debate among psychiatrists in the UK has surrounded such
matters as the perceived intrusiveness of spiritual assessment within the
clinical process, the strength of the evidence base, the danger of boundary
violations (e.g. proselytising), concerns about psychiatrists praying with
patients, and the lack of training and competence of psychiatrists to address
spiritual or religious matters that may arise in the course of clinical work.
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Good Psychiatric Practice requires that a psychiatrist be competent
in obtaining a full and relevant history, which includes social and cultural
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Position Statement PS03/2011
factors, and in undertaking a comprehensive mental state examination.
6
It
further requires that:
A psychiatrist must provide care that does not discriminate and is
sensitive to issues of gender, ethnicity, colour, culture, lifestyle, beliefs,
sexual orientation, age and disability (para. 13).
And again:
When negotiating the aims and outcomes of treatment plans, a
psychiatrist must recognise and respect the diversity of patients
lifestyles, including cultural issues, religious and spiritual beliefs,
ambitions and personal goals (para. 31).
A recent College Occasional Paper, Improving In-patient Mental Health
Services for Black and Minority Ethnic Patients, has made recommendations
for appropriately addressing matters of faith and spirituality within the
in-patient setting for members of Black and minority ethnic groups.
7
A
recent publication by some of the Colleges Spirituality and Psychiatry Special
Interest Group members and other contributors explores the relevance of
spirituality to the clinical practice of psychiatry.
8
However, until now, the
Royal College of Psychiatrists has not provided wider guidance or policy on
managing matters of spirituality or religion in clinical practice.
DEFINITIONS
Both spirituality and religion are terms which lack a universally agreed
defnition, and both are concerned in a broad sense with symbolic systems
which provide meaning to everyday life.
9
Spirituality is usually understood in a more subjective, experiential and
individual way, although it does have a social and traditional dimension. For
example, it has been defned as:
a distinctive, potentially creative, and universal dimension of human
experience arising both within the inner subjective awareness of
individuals and within communities, social groups and traditions. It
may be experienced as a relationship with that which is intimately
inner immanent and personal, within the self and others, and/or
as relationship with that which is wholly other, transcendent and
beyond the self. It is experienced as being of fundamental or ultimate
importance and is thus concerned with matters of meaning and purpose
in life, truth, and values.
10
Religion is usually defned more in terms of systems of beliefs and
practices related to the sacred or divine, and defnitions often refer to social
institutions and communities within which such systems are agreed and held
in common. However, others would see religion as much more individual
than social, and yet others would focus less on religion as being concerned
with belief systems and more on its concerns with morality, praxis or faith.
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The scope and variability of defnitions for both terms is enormous, with
some people identifying spirituality and religion as virtually synonym ous,
or at least as overlapping concepts, while others see them as contrasting
or opposed categories. In many Western countries, both religion and
spirituality are now often faced with the context of a secular society, in which
most public discourse is conducted without reference to either religion or
spirituality. In this context, interest in spirituality has nonetheless burgeoned
in recent years. In many other parts of the world, religious tradition continues
to provide a shared frame of reference for public life and discourse.
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The evidence base
Whatever disagreements there might be on defnition, spirituality and
religion are concerned with the core beliefs, values and experiences of
human beings. Faith communities, and spiritual or religious practices, have
the potential to infuence the course of mental illness and attitudes towards
people with mental illness, for good or ill. A consideration of their relevance
to the origins, understanding and treatment of psychiatric disorders is
therefore an important part of clinical and academic psychiatry.
There is now an extensive evidence base in support of the relevance
of spirituality and religion in understanding the aetiology of many mental
disorders, the benefts of considering spirituality and religion within an
overall clinical assessment of a patients condition, and also the potential
benefts of considering spiritual and religious factors within treatment
planning. The number of papers published in this feld now runs into many
hundreds.
8,1214
Although the bulk of this literature reports positive fndings,
suggesting that the relationship between spirituality/religion and mental
health is a positive one, there are undoubtedly methodological criticisms that
can be levelled against much of the earlier research, and also alternative
interpretations that may be offered.
1517
It is clear that religious and spiritual
beliefs are powerful forces which may impart harmful as well as benefcial
effects.
18
In addition to the broader evidence for spirituality and religion in
relation to psychiatry, there is now particular interest in relation to a number
of specifc treatments which derive originally from spiritual or religious
traditions. Notably, mindfulness-based cognitive therapy is recommended in
the National Institute for Health and Clinical Excellence (NICE) guidelines for
relapse prevention for people who have experienced three or more previous
episodes of depression.
19
Twelve-step facilitation therapy has also been
shown to be effective in the treatment of alcohol dependence, especially
for individuals with supportive social networks,
20
and there is increasing
evidence in support of the value of compassion-focused therapy.
21
A number of surveys have shown that mental health service users
want spirituality to be considered within the context of the overall provision
of their care.
22,23
The ability of mental health professionals to address this
task appropriately depends upon awareness of religious diversity and ability
to explore sensitively a patients spiritual and/or faith tradition.
24,25
There are
anecdotal accounts of the task being handled insensitively in the UK
4
despite
the availability of a range of published and established tools to assist in the
process of conducting a spiritual assessment.
26,27
Increasingly, faith-based organisations are becoming involved in the
delivery of mental healthcare.
28,29
Mental health professionals therefore
need to understand the nature of their involvement and, when necessary,
should be equipped to work with them. In some areas of psychiatry, such
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Position Statement PS03/2011
as substance misuse, there is also a need to be familiar with spiritual but
not religious traditions, such as that of Alcoholics Anonymous and its sister
organisations.
30
It is in the nature of contemporary secularity that the
search for meaning is now frequently pursued outside established religious
or spiritual traditions.
31
The increasingly individualistic and subjective
approaches to spirituality that are being pursued in todays world require
greater sensitivity and awareness on the part of the psychiatrist than ever
before.
Whatever conclusion may be reached on the basis of the evidence,
there is now a suffcient body of evidence to suggest that spirituality
and religion are at least factors about which psychiatrists should be
knowledgeable, insofar as they have an impact on the aetiology, diagnosis
and treatment of mental disorders. Further, an ability to handle spiritual and
religious issues sensitively and empathically has a signifcant potential impact
upon the relationship between psychiatrist and patient.
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Clinical practice
Spiritual and religious considerations have important ethical implications for
the clinical practice of psychiatry. Among the relevant considerations here
are the research evidence, the diverse views on spirituality and religion
among psychiatrists, and the expressed collective and individual aspirations
of mental health service users.
In the course of their work with patients and colleagues, clinicians will
encounter a variety of attitudes towards spirituality and religion:
identifcation with a particular social or historical tradition (or
traditions)
adoption of a personally defned, or personal but undefned, spirituality
disinterest
antagonism.
If the engagement with the spirituality or religious beliefs and practices
(or lack of them) of the other person is mishandled, there is a risk that harm
may be caused.
In Good Medical Practice,
32
the General Medical Council (GMC) states:
You must not express to your patients your personal beliefs, including
political, religious or moral beliefs, in ways that exploit their vulnerability
or that are likely to cause them distress (para. 33).
Further guidance is provided in the GMCs Personal Beliefs and Medical
Practice:
33
Trust and good communication are essential components of the
doctorpatient relationship. Patients may fnd it diffcult to trust you
and talk openly and honestly with you if they feel you are judging them
on the basis of their religion, culture, values, political beliefs or other
non-medical factors. For some patients, acknowledging their beliefs or
religious practices may be an important aspect of a holistic approach to
their care. Discussing personal beliefs may, when approached sensitively,
help you to work in partnership with patients to address their particular
needs. You must respect patients right to hold religious or other beliefs
and should take those beliefs into account where they may be relevant
to treatment options. However, if patients do not wish to discuss their
personal beliefs with you, you must respect their wishes (para. 9).
It later continues:
You should not normally discuss your personal beliefs with patients
unless those beliefs are directly relevant to the patients care. You
must not impose your beliefs on patients, or cause distress by the
inappropriate or insensitive expression of religious, political or other
beliefs or views. Equally, you must not put pressure on patients to
discuss or justify their beliefs (or the absence of them) (para. 19).
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Psychiatric training
Given the evidence base, the clinical relevance and the ethical implications,
an understanding of religion and spirituality and their relationship to
the diagnosis, aetiology and treatment of psychiatric disorders should
be considered as essential components of both psychiatric training and
continuing professional development.
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Royal College of Psychiatrists
Conclusions
The evidence base and service user opinion suggest that spirituality and
religion are of signifcance in clinical practice and research. Good clinical
practice requires an awareness of the ethical and professional boundaries
associated with spirituality and religion in psychiatry and competence in
managing them appropriately, respectfully and sensitively.
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Recommendations
1 A tactful and sensitive exploration of patients religious beliefs and
spirituality should routinely be considered and will sometimes be an
essential component of clinical assessment.
2 Psychiatrists should be expected always to respect and be sensitive
to the spiritual/religious beliefs and practices of their patients or to
the lack of them, and of the families and carers of their patients. This
should normally include allowing and enabling patients to engage
in the practice of their chosen spiritual or religious tradition. Where
the psychiatrist has reason to believe that this may be harmful, any
advice or intervention offered concerning this should be sensitive
to: the patients right to practice their religion; the infuence upon
their spiritual/religious choices of any illness from which they may be
suffering; the views of the family and/or faith community; and advice
offered by chaplains or spiritual care advisors.
3 Psychiatrists should not use their professional position for proselytising
or undermining faith and should maintain appropriate professional
boundaries in relation to self-disclosure of their own spirituality/
religion.
4 Psychiatrists should work to develop appropriate organisational policies
which promote equality, understanding, respect and good practice in
relation to spirituality and religion.
5 Psychiatrists, whatever their personal beliefs, should be willing to work
with leaders/members of faith communities, chaplains and pastoral
workers in support of the well-being of their patients, and should
encourage all colleagues in mental health work to do likewise.
6 Psychiatrists should always respect and be sensitive to spiritual and
religious beliefs, or lack of them, among their colleagues.
7 Religion and spirituality and their relationship to the diagnosis,
aetiology and treatment of psychiatric disorders should be considered
as essential components of both psychiatric training and continuing
professional development.
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References
1. Committee on Religion and Psychiatry (1990) Guidelines Regarding Possible
Confict Between Psychiatrists Religious Commitments and Psychiatric Practice.
American Journal of Psychiatry, 147, 542.
2. Verhagen PJ, Cook CCH (2010) Epilogue: proposal for a World Psychiatric
Association consensus or position statement on spirituality and religion in
psychiatry. In Religion and Psychiatry: Beyond Boundaries (eds PJ Verhagen, HM
Van Praag, JJ Lpez-Ibor, et al): pp. 615632. Wiley-Blackwell.
3. Poole R, Higgo R (2011) Spirituality and the threat to therapeutic boundaries in
psychiatric practice. Mental Health, Religion & Culture, 14, 1929.
4. Poole R, Higgo R, Strong G, et al (2008) Religion, psychiatry and professional
boundaries [Letter]. Psychiatric Bulletin, 32, 356357.
5. Lepping P (2008) Religion, psychiatry and professional boundaries [Letter].
Psychiatric Bulletin, 32, 357.
6. Royal College of Psychiatrists (2009) Good Psychiatric Practice. Third Edition
(College Report CR154). Royal College of Psychiatrists.
7. Fitch C, Wilson M, Worrall A (2010) Improving In-patient Mental Health Services
for Black and Minority Ethnic Patients (Occasional Paper OP71). Royal College of
Psychiatrists.
8. Cook C, Powell A, Sims A (eds) (2009) Spirituality and Psychiatry. RCPsych
Publications.
9. Hanegraaff WJ (2000) New age religion and secularization. Numen: International
Review for the History of Religions, 47, 288312.
10. Cook CCH (2004) Addiction and spirituality. Addiction, 99, 539551.
11. Bowker J (1999) The Oxford Dictionary of World Religions. Oxford University
Press.
12. Koenig HG, McCullough ME, Larson DB (2001) Handbook of Religion and Health.
Oxford University Press.
13. Koenig HG (2009) Research on religion, spirituality, and mental health: a review.
Canadian Journal of Psychiatry, 54, 283291.
14. Verhagen PJ, Van Praag HM, Lpez-Ibor JJ, et al (eds) (2010) Religion and
Psychiatry: Beyond Boundaries. Wiley-Blackwell.
15. Sloan RP, Bagiella E, Powell T (1999) Religion, spirituality and medicine. Lancet,
353, 664667.
16. King M, Leavey G (2010) Spirituality and religion in psychiatric practice: why all
the fuss? Psychiatrist, 34, 190193.
17. Sloan RP (2006) Blind Faith: The Unholy Alliance of Religion and Medicine. St
Martins Press.
18. Crowley N, Jenkinson G (2009) Pathological spirituality. In Spirituality and
Psychiatry (eds C Cook, A Powell, A Sims): pp. 254272. RCPsych Publications.
19. National Institute for Health and Clinical Excellence (2009) Depression: The
Treatment and Management of Depression in Adults. NICE.
20. Project MATCH Research Group (1998) Matching alcoholism treatments to client
heterogeneity: Project MATCH three-year drinking outcomes. Alcoholism, Clinical
and Experimental Research, 22, 13001311.
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Position Statement PS03/2011
21. Gilbert P (2010) Compassion Focused Therapy: Distinctive Features. Routledge.
22. McCord G, Gilchrist VJ, Grossman SD, et al (2004) Discussing spirituality with
patients: a rational and ethical approach. Annals of Family Medicine, 2, 356361.
23. Mental Health Foundation (2002) Taken Seriously: The Somerset Spirituality
Project. Mental Health Foundation.
24. Richards PS, Bergin AE (eds) (2000) Handbook of Psychotherapy and Religious
Diversity. American Psychological Association.
25. Salem MO, Foskett J (2009) Religion and religious experiences. In Spirituality and
Psychiatry (eds C Cook, A Powell, A Sims): pp. 233253. RCPsych Publications.
26. Culliford L, Eagger S (2009) Assessing spiritual needs. In Spirituality and
Psychiatry (eds C Cook, A Powell, A Sims): pp. 1638. RCPsych Publications.
27. Aten JD, Leach MM (eds) (2009) Spirituality and the Therapeutic Process: A
Comprehensive Resource from Intake to Termination. American Psychological
Association.
28. Leavey G, King M (2007) The devil is in the detail: partnerships between
psychiatry and faith-based organisations. British Journal of Psychiatry, 191,
9798.
29. Cognac HG (2005) Faith and Mental Health. Templeton Foundation Press.
30. Cook CCH (2009) Substance misuse. In Spirituality and Psychiatry (eds C Cook,
A Powell, A Sims): pp. 139168. RCPsych Publications.
31. Taylor C (2007) A Secular Age. Belknap.
32. General Medical Council (2006) Good medical practice. GMC.
33. General Medical Council (2008) Personal beliefs and medical practice. GMC
(http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs.asp).
DISCLAIMER
This guidance (as updated from time to time) is for use by members of the Royal College of
Psychiatrists. It sets out guidance, principles and specifc recommendations that, in the view of the
College, should be followed by members. None the less, members remain responsible for regulating
their own conduct in relation to the subject matter of the guidance. Accordingly, to the extent
permitted by applicable law, the College excludes all liability of any kind arising as a consequence,
directly or indirectly, of the member either following or failing to follow the guidance.